Anesthesia Coding Alert

4 steps to clarifying muscle injections.

If youre a PM coder wanting to perfect your trigger point injection (TPI) claims, use these questions to uncover the details of TPIs.

1. What Patients Needs TPIs?

Most patients who require TPIs suffer from muscle or head pain. Trigger points are knots of muscle that form when muscles do not relax. Headaches are another reason that physicians perform TPI, explains Joanne Mehmert,CPC, CCS-P, owner of Joanne Mehmert & Associates in Kansas City.

When your pain management specialist performs TPIs, the most common diagnosis reported is 729.1 (Myalgia and myositis, unspecified), says Judith Blaszczyk, RN, CPC, ACS-PM, president of Veritas Consulting in Greencastle, Pa.

Watch out: Your physician might also use these synonyms for myalgia/myositis in the documentation:myofascitis, myofascial pain, or fibromyalgia. Code any of these diagnoses with 729.1, Mehmert recommends.

Other diagnoses that might accompany a TPI claim include muscle spasm (728.85) or torticollis (723.5).

Physicians sometimes document only the location of the pain -- neck pain, low back pain, or headache. With trigger point injections, physicians should indicate more specifically the etiology of the pain, Blaszczyk says. For instance, it would help to distinguish if the pain is from muscular spasm rather than an old fracture.

According to CPT Assistant, other possible indications for TPIs could include:

" plantar fasciitis (728.71)

" chronic lower back pain (724.2)

" osteoarthritis (715.xx)

" multiple sclerosis (340)

" joint disease (719.9x)

" scoliosis (737.3x)

" herniated/degenerative disks (722.2, 722.6).

Many payers have limited TPI payment policies -- and the physician can perform TPI on any of the 600-plus muscles in the human body, Mehmert says. It's crucial for you to check with each payer to see what it considers medically necessary for TPIs, as policy can vary widely from insurer to insurer.

2. What Separates 20552, 20553 Claims?

Simply, the number of muscles the physician injects. If she injects two or fewer muscles, report 20552 (Injection[s];single or multiple trigger point[s], 1 or 2 muscle[s]).

When your physician performs TPI on three or more muscles, report 20553 (& single or multiple trigger point[s], 3 or more muscle[s]), says Annette Grady,CPC-Ortho, CPC-H, CPC-I, CPC-P, CCS-P, PCS,FCS, senior compliance auditor with The Coding Network, during a recent audio conference on www.codinginstitute.com.

Example 1: An established patient presents with intense neck and shoulder pain. The physician performs five injections on a patients scapulae and three on her sternocleidomastoid. Report 20552 in this scenario, as the physician performed TPIs on two muscles.

Example 2: An established patient complains of severe lower back pain. The physician performs a single TPI to the patients quadratus lumborum, and two shots each to his gluteus maximus and gluteus minimus. Report 20553 in this scenario, as the physician performed TPIs on three muscles.

3. When Can You Code Separately for the Drug?

Your pain management specialist might perform TPI with a steroid, Mehmert points out. The steroids your physician is most likely to use during TPIs are:

" triamcinolone acetonide (also known as Kenalog);J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) per 10 mg

" methylprednisolone acetate (also known as Depo-Medrol); J1020 (Injection, methylprednisolone acetate, 20 mg), J1030 (& 40 mg), J1040 (& 80 mg).

You can typically code separately for TPI steroids in the office setting as long as your physician bought the drugs. If you have any doubt as to a specific payers policy (Medicare or otherwise), check your contract before coding steroids separately.

Your physician may also inject an anesthetic during TPI. Medicare will not pay separately for anesthetic drugs he might inject during a TPI, though some other payers might, depending on the drug. If your physician injects an anesthetic such as lidocaine or bupivacaine, there really is no appropriate J code, and there are not many payers that will reimburse for [these drugs] because they are considered local anesthetics, explains Blaszczyk.

Best bet: Check with the insurer before coding separately for lidocaine, bupivacaine, etc. Insurers that will pay likely require you to report J3490 (Unclassified drugs), and indicate in the narrative the name and amount of the drug, Blaszczyk says.

4. Why Keep TPI Patient Documentation?

If the auditor comes calling about a TPI claim, you'll be able to prove medical necessity easily if you keep certain information on file.

On your TPI claims, keep a record of the muscles the physician injects, Mehmert recommends. Also, documentation of the medical necessity for the procedure should be clear. Included in this would be documentation of a brief pain history, the location of the pain, the pre-injection intensity of the pain, prior treatment, and responses, says Blaszczyk.

Check out this example of solid documentation for a scenario in which the FP provides an E/M service (99201-99215 with modifier 25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] appended) leading to TPIs (20552):

43-YO male with 3-week history of occipital, cervical neck pain. Unrelieved by over-the-counter pain medications,heat, or muscle relaxers. Pt describes pain as sharp,unrelenting, and 8 out of 10 on the pain scale. Palpable TPs found in trapezius and quadratus lumborum muscles. Injected each TP twice with 30cc of lidocaine. Patient tolerated treatment well; post-TPI pain rating a 2.